What is the recommended management for the 3rd stage of labor?

Management of the Third Stage of Labor

Active management of the third stage of labor should include immediate administration of oxytocin (5-10 IU intramuscular or slow intravenous) at the time of anterior shoulder delivery or immediately after birth of the infant, combined with delayed cord clamping for approximately 60 seconds and controlled cord traction when feasible. 1, 2

Core Components of Third Stage Management

Uterotonic Administration (First Priority)

Oxytocin is the first-line uterotonic agent for all deliveries:

• Administer 10 IU oxytocin intramuscularly immediately after delivery of the anterior shoulder or complete delivery of the infant 1, 3
• Alternatively, 5-10 IU can be given via slow intravenous injection over 1-2 minutes 1, 2
• Intravenous infusion (20-40 IU in 1000 mL at 150 mL/hour) is acceptable but less practical 3
• Oxytocin administration should occur before placental delivery to maximize effectiveness 2, 4

Enhanced prophylaxis regimens for higher-risk situations:

• Oxytocin plus tranexamic acid: Add 1g tranexamic acid IV to standard oxytocin dose for enhanced hemorrhage prevention 1, 4
• Oxytocin plus misoprostol: Add 400 µg sublingual misoprostol to oxytocin 10 IU for vaginal deliveries 4
• Carbetocin: Single dose of 100 µg IV or IM is highly effective, particularly for cesarean deliveries 4, 3

Cord Management

Delayed cord clamping should be standard practice:

• Delay cord clamping for approximately 60 seconds (1-3 minutes) after delivery 1, 4
• This improves neonatal outcomes without increasing maternal blood loss 1
• Administer oxytocin immediately after infant delivery while cord remains intact 1

Controlled cord traction:

• Apply controlled cord traction during placental delivery when feasible 1, 4
• This intervention reduces hemorrhage risk by 50-66% when combined with oxytocin 5
• The benefit is most pronounced when oxytocin is given intramuscularly 5

Contraindicated Medications

Ergometrine (methylergonovine) should be avoided in most routine cases:

• Absolutely contraindicated in women with hypertension, preeclampsia, or respiratory conditions (asthma, bronchiectasis) 6, 1
• Causes bronchospasm and hypertensive crises 1
• May be considered only as second-line therapy in normotensive women without respiratory disease 3
• If used, dose is 0.2 mg intramuscularly 7, 3

Prostaglandin F2α should be avoided in women with asthma due to risk of bronchoconstriction 1

Special Clinical Situations

Women with Cardiac Disease (Peripartum Cardiomyopathy)

• Use single intramuscular dose of oxytocin for third stage management 6
• Ergometrine is absolutely contraindicated in cardiac patients 6
• Consider single IV dose of furosemide after delivery to prevent fluid overload from autotransfusion 6
• Monitor for increased preload from autotransfusion of blood from lower limbs and contracted uterus 6

Women on Anticoagulation

• Pay careful attention to minimizing trauma during delivery 1
• Active management with uterotonics is essential to enhance uterine contraction and reduce bleeding risk 1
• Restart anticoagulants only after postpartum bleeding has stopped and epidural catheter removed 6

Low-Resource Settings Without IV Access

• Administer 10 IU oxytocin intramuscularly plus 400 µg sublingual misoprostol 4
• This combination is effective when IV access is unavailable 4

Interventions NOT Recommended

Routine uterine massage is not recommended:

• The WHO does not support sustained uterine massage as routine practice 1
• Evidence suggests it may actually increase hemorrhage risk 5
• Reserve for treatment of atony, not prophylaxis 1

Manual placental removal should not be routine:

• Do not perform manual removal to reduce hemorrhage risk outside specialized centers 1
• Only indicated for severe uncontrollable hemorrhage or retained placenta beyond 30-45 minutes 3

Cord drainage has insufficient evidence and cannot be recommended as routine practice 3

Critical Pitfalls to Avoid

• Never give ergometrine to hypertensive or asthmatic patients - risk of severe complications 6, 1
• Do not delay oxytocin administration - give immediately at shoulder delivery, not after placental delivery 1, 2
• Avoid rapid IV bolus of oxytocin in cesarean sections - associated with hypotension; use slow administration over 1-2 minutes 3
• Do not use misoprostol as sole agent when oxytocin is available - inferior efficacy with more side effects (shivering, fever) 8

Postpartum Considerations

• Initiate early skin-to-skin contact immediately after delivery 4
• Monitor for signs of hemorrhage using clinical markers rather than visual estimation 3
• Have emergency PPH equipment readily available in all delivery settings 3